Coverage is provided by the following entities: Aetna Health of California Inc 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Choice of Coverage' section. Select your desired medical plan and indicate any applicable deductibles or coinsurance options.
3. Complete the 'Employee Information' section, ensuring you provide your full name, address, and contact details clearly.
4. In the 'Employee/Family Information' section, list all individuals for whom you are enrolling or changing coverage. Include their names, birth dates, and relationship to you.
5. If applicable, provide health history for enrolled members in the designated area. This includes any recent hospitalizations or medications taken.
6. Review all information for accuracy. Ensure all required signatures and dates are included before submitting the form.

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